Healthcare Provider Details

I. General information

NPI: 1306296116
Provider Name (Legal Business Name): MR. GABRIEL JOSEPH KANAWITE SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: GABRIEL JOSEPH KANAWITE SR. LSAA

II. Dates (important events)

Enumeration Date: 06/13/2016
Last Update Date: 01/26/2026
Certification Date: 01/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 GOLD AVE SW STE 1300W
ALBUQUERQUE NM
87102-3283
US

IV. Provider business mailing address

400 GOLD AVE SW STE 1300W
ALBUQUERQUE NM
87102-3283
US

V. Phone/Fax

Practice location:
  • Phone: 505-369-4324
  • Fax:
Mailing address:
  • Phone: 505-369-4324
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number0065872
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: